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,%e Appendix VI .ri MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: PERSHING BEACON Bldg. No.: Site Address: 4445 E PERSHING City: STOCKTON CA Zip: Facility Contact Person: Cheema Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT SIMPLICITY Date of Testing/Servicing: 1-29-2015 B. Inventory of Equipment Tested/Certified shark tha nnnrnnriatn hree. to indicate specific equipment ins Dected/serviced: Tank ID: 87 Tank ID: 91 ® In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: MAG t ® Annular Space or Vault Sensor. Model: 302 0 Annular Space or Vault Sensor. Model: 302 19 Piping Sump / Trench Sensor(s). Model: 352 ® Piping Sump / Trench Sensor(s). Model: 352 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model. PLLD 4 Electronic Line Leak Detector. Model: PLED ❑ Tank Overfill / High -Level Sensor. Model. ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: DSL Tank ID: WASTE OIL ® In -Tank Gauging Probe. Model: MAG 1 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 302 ® Annular Space or Vault Sensor. Model: 420 ® Piping Sump / Trench Sensor(s). Model: 352 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: .0 Electronic Line Leak Detector. Model : PLLD ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: 0 Tank Overfill / High -Level Sensor. Model: 420 Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 5-8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Floats) and Chain(s). ® Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3-4 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ❑ Shear Valve(s). ® Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: DispenserlD: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Valve(s). 1I Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). 'If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser aline racntry. C. Certification -I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): ® System set-up ® Alarm history report Technician Name (print): DAVE WINKLER Signature: Certification No.: 5283373 -UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0112 Testing Company Address: 4162 STREET GALT, CA 95832 _ Date of Testing/Sentlang: 1-29-2015 Monitoring System Certification Page 1 of 4 RECEIVE Y1/07 MAR 19 2015 ENVIRONMENTAL HEALTH ,%)0— \C 04 PERMIT/SERVICES